Royse City Independent School District School Health Services

Date of Plan: _______________

Diabetes Medical Management Plan This plan should be completed by the student’s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel. Effective Dates: _______________________________________________________________ Student’s Name: _______________________________________________________________ Date of Birth: _______________________ Date of Diabetes Diagnosis: __________________ Grade: _____________________________ Homeroom Teacher: ________________________ Physical Condition:

Diabetes type 1

Diabetes type 2

Contact Information Mother/Guardian: _____________________________________________________________ Address: _____________________________________________________________________ ____________________________________________________________________________ Telephone: Home __________________ Work _________________ Cell_________________ Father/Guardian: ______________________________________________________________ Address: _____________________________________________________________________ _____________________________________________________________________________ Telephone: Home _________________ Work __________________ Cell _________________ Student’s Doctor/Health Care Provider: Name: _______________________________________________________________________ Address: _____________________________________________________________________ Telephone: ________________________ Emergency Number: __________________________ Other Emergency Contacts: Name: _______________________________________________________________________ Relationship: __________________________________________________________________ Telephone: Home _________________ Work _________________ Cell __________________ Notify parents/guardian or emergency contact in the following situations: __________________ _____________________________________________________________________________ _____________________________________________________________________________

Blood Glucose Monitoring Target range for blood glucose is

70-150

70-180

Other __________________

Usual times to check blood glucose ________________________________________________ Times to do extra blood glucose checks (check all that apply) before exercise after exercise when student exhibits symptoms of hyperglycemia when student exhibits symptoms of hypoglycemia other (explain): ____________________________________________________________ Can student perform own blood glucose checks?

Yes

No

Exceptions: __________________________________________________________________ ____________________________________________________________________________ Type of blood glucose meter student uses: __________________________________________ ____________________________________________________________________________ Insulin Usual Lunchtime Dose Base dose of Humalog/Novolog /Regular insulin at lunch (circle type of rapid-/short-acting insulin used) is _____ units or does flexible dosing using _____ units/ _____ grams carbohydrate. Use of other insulin at lunch: (circle type of insulin used): intermediate/NPH/lente _____ units or basal/Lantus/Ultralente _____ units. Insulin Correction Doses Parental authorization should be obtained before administering a correction dose for high blood glucose levels.

Yes

No

_____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl Can student give own injections?

Yes

No

Can student determine correct amount of insulin?

Yes

No

Can student draw correct dose of insulin?

Yes

No

_______ Parents are authorized to adjust the insulin dosage under the following circumstances: _____________________________________________________________________________ _____________________________________________________________________________

For Students with Insulin Pumps Type of pump: _______________________ Basal rates: _____ 12 am to _____ _____ _____ to _____ _____ _____ to _____ Type of insulin in pump: ________________________________________________________ Type of infusion set: ____________________________________________________________ Insulin/carbohydrate ratio: ________________________ Correction factor: ________________ Student Pump Abilities/Skills:

Needs Assistance

Count carbohydrates

Yes

No

Bolus correct amount for carbohydrates consumed

Yes

No

Calculate and administer corrective bolus

Yes

No

Calculate and set basal profiles

Yes

No

Calculate and set temporary basal rate

Yes

No

Disconnect pump

Yes

No

Reconnect pump at infusion set

Yes

No

Prepare reservoir and tubing

Yes

No

Insert infusion set

Yes

No

Troubleshoot alarms and malfunctions

Yes

No

For Students Taking Oral Diabetes Medications Type of medication: ____________________________________ Timing: ________________ Other medications:

___________________________________ Timing: ________________

Meals and Snacks Eaten at School Is student independent in carbohydrate calculations and management?

Yes

No

Meal/Snack

Time

Food content/amount

Breakfast

______________________

__________________________________

Mid-morning snack

______________________

___________________________________

Lunch

______________________

___________________________________

Mid-afternoon snack ______________________

___________________________________

Dinner

___________________________________

______________________

Snack before exercise?

Yes

No

Snack after exercise?

Yes

No

Other times to give snacks and content/amount: _____________________________________________________________________________ Preferred snack foods: _____________________________________________________________________________ Foods to avoid, if any: _____________________________________________________________________________ Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event): _______________________________________________________________________ _____________________________________________________________________________ Exercise and Sports A fast-acting carbohydrate such as _________________________________________________ should be available at the site of exercise or sports. Restrictions on activity, if any: _______________________________________ student should not exercise if blood glucose level is below ____________________ mg/dl or above ____________________ mg/dl or if moderate to large urine ketones are present. Hypoglycemia (Low Blood Sugar) Usual symptoms of hypoglycemia: ________________________________________________ _____________________________________________________________________________ Treatment of hypoglycemia:______________________________________________________ _____________________________________________________________________________ Glucagon should be given if the student is unconscious, having a seizure (convulsion), or unable to swallow. Route _______, Dosage _______, site for glucagon injection: _______arm, _______thigh, _______other. If glucagon is required, administer it promptly. Then, call 911 (or other emergency assistance) and the parents/guardian. Hyperglycemia (High Blood Sugar) Usual symptoms of hyperglycemia: ________________________________________________ _____________________________________________________________________________ Treatment of hyperglycemia: _____________________________________________________ _____________________________________________________________________________ Urine should be checked for ketones when blood glucose levels are above _________ mg/dl. Treatment for ketones: __________________________________________________________ _____________________________________________________________________________ Supplies to be Kept at School _______Blood glucose meter, blood glucose test strips, batteries for meter

_______ Lancet device, lancets, gloves, etc. _______Urine ketone strips _______Insulin pump and supplies _______Insulin pen, pen needles, insulin cartridges _______Fast-acting source of glucose _______Carbohydrate containing snack _______Glucagon emergency kit Signatures This Diabetes Medical Management Plan has been approved by: _________________________________________________

_______________________

Student’s Physician/Health Care Provider

Date

I give permission to the school nurse, trained diabetes personnel, and other designated staff members of ______________________________ school to perform and carry out the diabetes care tasks as outlined by __________________________’s Diabetes Medical Management Plan. I also consent to the release of the information contained in this Diabetes Medical Management Plan to all staff members and other adults who have custodial care of my child and who may need to know this information to maintain my child’s health and safety. Acknowledged and received by: _________________________________________________

______________________

Student’s Parent/Guardian

Date

_________________________________________________

______________________

Student’s Parent/Guardian

Date